Collaboration and cooperation systems to prevent suicide among children in Japan: effective use of the Observe-Orient-Decide-Act loop

Japan is the only G7 country where suicide is the leading cause of death among youths (ages 10–29 and 15–34). COVID-19 has adversely affected children’s mental health, increasing anxiety, depression, self-injury, school attendance difficulties, and suicide. Schools are central to children’s daily lives, necessitating timely collaboration with medical and welfare institutions, especially for high-risk children who report poor health. However, teachers face long hours and stress, hindering effective interprofessional collaboration. Conventional PDCA cycles used in case management and interprofessional work are slow and inflexible in rapidly changing or emergency situations. The study posits that the OODA loop, emphasizing rapid observation, orientation, decision, and action with continuous feedback, may better support dynamic, responsive collaboration across education and health/welfare sectors. The study aims to clarify: (1) education personnel’s awareness of their own health and mental health; (2) their attitudes toward the OODA loop; and (3) their perceptions of current collaboration/cooperation to provide a basis for introducing OODA into these systems.

Prior work highlights the need for robust interprofessional collaboration in education and healthcare, including models from social work and interprofessional education (Bronstein 2003; D’Amour et al. 2005; Bridges et al. 2011; Reeves et al. 2018; Schot et al. 2020; Folkman et al. 2019). In Japan, researchers emphasize building awareness and systems for professional collaboration between schools and medical institutions and clarifying roles (Saito and Asakura 2020; Ichikawa et al. 2022; Mimura et al. 2019). The PDCA cycle, prevalent in management and current school-based collaboration, has limitations under uncertainty and emergencies, often being slow and plan-heavy with insufficient flexibility (Ohnishi and Fukumoto 2016; Murooka et al. 2017; Fukuda 2010; Fukami and Nagao 2022). The OODA loop, developed by John Boyd, has been applied successfully in emergencies, disaster management, clinical practice, and cybersecurity for flexible, rapid decision-making with continuous feedback (Coram 2002; Dag et al. 2008; Villars et al. 2008; Wickramasinghe et al. 2009; Vettorello et al. 2019; Husák et al. 2022). Despite its use in other fields, application of OODA to education-sector interprofessional collaboration has not been studied. Self-rated health is a validated, reliable predictor of general health and mortality and is associated with depression, making it a useful indicator for educators’ well-being (Mossey and Shapiro 1982; Lundberg and Manderbacka 1996; Kaplan and Camacho 1983; Okado et al. 2000; Palladino et al. 2016; Hone et al. 2016; Okada et al. 2022). The K6 is a validated screen for depressive symptoms (Kessler et al. 2002; Furukawa et al. 2003; Sakurai et al. 2011; Ferro 2019; Umucu et al. 2021; Mitchell and Beals 2011; Hajebi et al. 2018).

Design: Cross-sectional, anonymous, self-administered questionnaire survey. Participants and setting: 205 professionals (teachers, nurses, welfare professionals, school counsellors) from schools and related facilities in five Japanese cities (population 30,000–100,000) were approached; 171 provided valid responses (82 men, 88 women, 1 other). Cities were chosen as representative in size, gender ratio, and academic performance. Power analysis assumed medium effect size (d=0.5), alpha 0.5% (text states 0.5%, likely typographical; analysis used standard 5% for tests), power 0.8, with a minimum n=128. Study period and procedure: October 2021–October 2022. Researchers visited schools, training seminars, and case meetings to distribute study information and obtain consent. The survey was anonymous. Measures: - Self-rated health: Two items assessing physical and mental health separately: “Do you generally consider yourself physically healthy?” and “Do you generally consider yourself mentally healthy?” rated on 4-point scale (1=very healthy to 4=not healthy). - Depressive symptoms: Kessler Psychological Distress Scale (K6), 6 items scored 0–4 each (0–24 total); cut-off ≥5 indicates risk of depressive/anxiety disorders. Mean K6 used for analysis. - Collaboration: Awareness of OODA (heard/meaning), prior training on coordination/collaboration. Experience of collaboration/cooperation with other professionals (yes/no). Among those with experience: satisfaction with current collaboration/cooperation and open-ended reasons. - Attitudes toward OODA-based collaboration: An original 17-item scale (5-point Likert, 1=none of the time to 5=all of the time) developed from literature on OODA and collaborative practice. After factor analysis, 16 items retained. Ethics: Approved by the Medical Ethics Committee of Kochi University (FY 2020, approval number: 6). Written informed consent obtained; anonymity ensured; adherence to the Declaration of Helsinki. Analysis: SPSS 28.0J. Factor analysis on OODA attitude items (unweighted least squares, promax rotation). Cronbach’s alpha for internal consistency. Point-biserial correlations between factor scores and satisfaction with collaboration. ANOVA (with Tukey HSD) across professions for self-rated health, OODA factors, and K6. Independent t-tests for experience vs no experience of collaboration, and for satisfied vs dissatisfied among those with collaboration experience. Qualitative content analysis of open-ended responses by a multidisciplinary team; reasons categorized into details, methods, and organisations for collaboration/cooperation. Significance level set at 5%.

Sample: 171 valid respondents (82 men, 88 women, 1 other). None had heard of the OODA loop or received training on coordination/collaboration specifically referencing OODA. Factor analysis of OODA attitude scale: One item removed (“Always separating judgement and decision-making”). A 3-factor, 16-item solution emerged (initial eigenvalues 7.74 to 1.23; cumulative variance explained 63.0%). Factors: - Factor 1: Flexible and independent situational assessment (11 items; α=0.909). - Factor 2: Group monitoring and sharing (4 items; α=0.882). - Factor 3: Self-monitoring (2 items; α=0.665). Validity: Positive point-biserial correlations between satisfaction with current collaboration and all three factors: Factor 1 rpb=0.204 (n=136, P=0.017); Factor 2 rpb=0.197 (n=136, P=0.022); Factor 3 rpb=0.175 (n=136, P=0.041). Experience and satisfaction: 136 (79.5%) had experience with collaboration/cooperation; among them, 101 (74.3%) were satisfied and 35 (25.7%) dissatisfied. Group comparisons by profession (teachers, guidance officers, healthcare workers, counsellors, other supporters): No significant differences in self-rated physical/mental health, OODA factor scores, or K6 (all ANOVA P>0.18). Experience vs no experience (t-tests): No significant differences in self-rated health (physical/mental), OODA factors, or K6 (all P≥0.057). Satisfaction vs dissatisfaction among those with experience (t-tests): Significant differences favoring satisfied group in: - Self-rated physical health: t(134)=2.111, P=0.037, d=0.414 (satisfied better). - Self-rated mental health: t(134)=2.064, P=0.042, d=0.333 (satisfied better). - OODA attitudes: Factor 1 t=2.406, P=0.017, d=0.472; Factor 2 t=2.073, P=0.043, d=0.456; Factor 3 t=2.060, P=0.041, d=0.404. - K6: no significant difference, t=-0.368, P=0.714. Qualitative reasons for satisfaction vs dissatisfaction: - Details of collaboration/cooperation: Satisfaction linked to sharing information, receiving professional advice, clarity on future management and goals; dissatisfaction linked to lack of information, insufficient communication, lack of specific measures. - Methods: Satisfaction tied to appropriate, regular management and progression; dissatisfaction to slow responses, unproductive case conferences, lack of concrete actions or solutions. - Organisations: Satisfaction associated with cooperative attitudes, role-sharing, multiprofessional work, stepwise progress, referrals; dissatisfaction with staffing shortages, frequent relocations, time constraints, insufficient interactions, unclear roles, different perspectives, lack of common assessment and information sharing.

The study addresses the need for rapid, flexible collaboration to prevent suicide among high-risk school-age children by assessing educators’ mental health, attitudes toward OODA, and perceptions of current collaboration. While mental health status did not differ by profession or by experience with collaboration, satisfaction with current collaboration was associated with better self-rated physical and mental health. This suggests that the quality and effectiveness of collaboration influences educators’ perceived well-being, even if not reflected in K6 depressive symptom scores. The newly developed OODA attitude scale showed good reliability and content validity and correlated positively with satisfaction, implying that adopting OODA-aligned attitudes (rapid situational assessment, sharing within teams, and self-monitoring) relates to better perceived collaboration. Dissatisfied participants scored lower on all OODA factors, indicating more passive or less adaptive decision-making orientations. Qualitative findings reinforce these patterns: satisfied respondents described meaningful advice, clear goals, cohesive teamwork, and actionable steps; dissatisfied respondents emphasized information gaps, slow and unproductive processes, unclear roles, and organizational barriers. Collectively, the results support the premise that OODA-oriented collaboration—enabling timely observation, orientation, decision-making, and action with feedback—may enhance interprofessional work between schools and medical/welfare services, potentially alleviating teacher burden and improving responsiveness to high-risk children.

Satisfaction with the current status of interprofessional collaboration is associated with better self-rated health among education personnel and with more positive attitudes toward OODA-based collaboration. The study contributes a reliable, content-valid scale to assess OODA-related attitudes in educational collaboration contexts and identifies organizational and process elements that differentiate satisfactory from unsatisfactory collaboration. To effectively leverage OODA in school–medical/welfare collaboration, the authors recommend: raising awareness and training on OODA concepts among teaching personnel; creating organizational structures led by administrators to support rapid, flexible collaboration; establishing systems that enable organic, timely cooperation and decision-making; and incorporating external review mechanisms. Future research should include broader, nationally representative and cross-country samples, utilize mixed methods (e.g., interviews), evaluate implementation of OODA-based interventions, and integrate perspectives of external support institutions.

- Sampling from five cities/prefectures; not nationally representative. - Cross-sectional design and reliance on self-reported questionnaires; lacks qualitative depth beyond brief open-ended items. - Cultural context of Japan may limit generalizability; replication in other countries recommended. - The OODA attitude scale, though reliable with preliminary validity, requires further validation over time and across contexts. - Lack of actual implementation trial of OODA-based collaboration; causal inferences cannot be drawn.